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: XS: 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.

INTRODUCTION

Pelvic organ prolapse (POP) as a consequence of pelvic floor descent involves internal and external rectal prolapse, uterus and vaginal prolapse as well as the development of cystoceles, enteroceles and rectoceles. Abdominal rectopexy and colpopexy are established surgical techniques restoring the anatomy and function. The promontory of the sacrum is widely used as the proximal fixation point for various techniques of open, and nowadays more frequently, laparoscopic-or robotic-assisted, recto- and colpopexy. Depending on the technique, the organ fixation is either performed by direct sutures or by using a mesh that is sutured or tacked to the promontory of the sacrum. Concerning rectopexy, posterior rectopexy (PR) involving a complete posterior and anterior rectal mobilisation down to pelvic floor with or without dissection of the lateral ligaments is distinguished from ventral rectopexy (VR) limiting the rectal mobilisation to the ventral aspect of the organ including opening of the recto-vaginal septum. In VR, a synthetic or biologic mesh is placed on the ventral aspect of the rectum and fixated with sutures or glue on the rectum. While VR is a nerve-sparing procedure with the absence of de novo constipation in PR a sigmoid resection is usually added to avoid postoperative de novo constipation. Moreover, the recurrence rate is lowered when a sigmoid resection is performed in PR.[1] Similarly to VR in sacral colpopexy (SC), a mesh is fixated to the anterior and posterior aspect of the vagina with proximal mesh fixation to the anterior longitudinal ligament of the sacrum. In general, the fixation on the sacral promontory is safe; however, spondylodiscitis (SD) after PR, VR and SC is a rare infectious complication that may have severe consequences including the need for mesh removal, reoperation, a prolonged hospital stay or even permanent disability.[23] We report a case of SD after laparoscopic PR and present a systematic literature review illustrating presentation, diagnosis and treatment of SD after PR, VR and SC.

METHODS

A comprehensive search of the electronic database MEDLINE (via PubMed) was carried out on May 26, 2018, with the following keyword algorithm: (discitis OR osteomyelitis OR SD) AND (colpopexy OR rectopexy OR sacropexy). In addition, the bibliographies of all included studies were searched by hand for appropriate references. Data from the included studies were entered into an Excel™ (Microsoft Corporation, Redmond, Washington, USA) database.

Eligibility criteria

Inclusion criteria were: Case reports or case series reporting on SD after PR, VR or SC in patients over 18 years of age.

Outcome measures

Outcomes measures were the time from initial surgery to SD, presenting symptoms, surgical approach, type of sacrum fixation technique, mesh material, occurrence of mesh erosion or fistula formation and type of treatment.

Study selection

Two independent investigators screened and selected all titles and abstracts based on the predefined eligibility criteria. Full-text articles were reviewed by two authors, who independently extracted the data. Any discrepancies between the two reviewers were resolved by discussion with a third author.

Statistical analysis

Continuous data were expressed as median (interquartile range).

RESULTS

Case presentation

A 60-year-old woman was admitted to our hospital with a history of lower abdominal pain due to recurrent diverticulitis as well as symptoms of obstructed defecation. Computed tomography (CT) showed a fixated sigmoid loop with a consequent inflammatory stenosis. Defecography revealed a deep recto-rectal intussusception (Oxford Grade III) explaining obstructed defecation. A laparoscopic PR with fixation of the dorsal rectal wall to the anterior ligament of the promontory of the sacrum with three permanent monofilament sutures and a sigmoid resection with an end-to-side descendo-rectostomy was performed.

The postoperative course was initially uneventful, and the patient discharged on the 5th postoperative day (POD). Two weeks later, she started suffering from slight back pain radiating in both legs, the pain progressed over the next weeks. Nine weeks after the initial surgery, she presented at the emergency department. Magnetic resonance imaging (MRI) showed bone marrow oedema at L5 and erosive osteochondrosis corresponding with progressive SD L5/S1 [Figure 1]. Furthermore, a fistula from the dorsal rectopexy to the anterior spinal ligaments and intervertebral disc L5/S1 was found. Laboratory findings included white blood cell count of 13.2/nl and C-reactive protein of 14.5 mg/l. Due to progressive paralysis of both legs, a neurosurgeon performed emergency posterior fenestration of L5/S1. During the surgery, a smear from the epidural space was taken. Five days later, fistula resection and resection of the anastomosis in the form of an open short colonic segment resection with the fashioning of a new anastomosis and a protective loop ileostomy was performed. Various abscesses were found in the area of the PR; however, the fistula was not in conjunction with the descendo-rectostomy. Empiric intravenous antibiotic therapy was initiated and adapted after the microbiological samples taken from the epidural space-tested positive for Pseudomonas aeruginosa, Enterococcus faecium and Enterococcus faecalis. The further course was uneventful and the patient was discharged on the 20 POD. Oral antibiotics were administered to treat the SD for 4 more weeks.

Figure 1

Magnetic resonance imaging showing bone marrow edema at L5 and erosive osteochondrosis corresponding with progressive spondylodiscitis L5/S1

Systematic review of the literature

Data extraction from electronic databases yielded a total of 29 abstracts, and hand searches of reference lists in available studies on the topic yielded a further 12 studies. Forty of these studies remained for full-text screening. Eight of the studies were excluded because they did not report on clinical cases. Therefore, a total of 31 studies reporting on 40 patients and the own case are included in this systematic review [Figure 2]. The included studies are presented in Table 1.

Figure 2

PRISMA flow diagram for the systematic review

Table 1

Studies included in the systematic review

Author	Age	Initial procedure	Complication	Time to complication	Treatment
Anand et al.[4]	70	Robotic hysterectomy, sacrocolpopexy	Spondylodiscitis, mesh erosion	90	Mesh removal, anterior discectomy, AB
Api et al.[5]	53	Laparoscopic total hysterectomy, sacrocolpopexy	Spondylodiscitis	6	Mesh removal, AB
	65	Open hysterectomy sacrocolpopexy	Spondylodiscitis	53	Mesh removal, AB
Apostolis and Heiselman[6]	66	Laparoscopic hysterectomy, salpingo-oophorectomy, sacrocolpopexy, transvaginal tape-sling	Sacral osteomyelitis, spondylodiscitis, epidural abscess	10	1. Laminectomy and debridement of epidural phlegmon 2. Mesh removal, AB
Arsene et al.[7]	NA	Hysterectomy, sacrocolpopexy	Spondylodiscitis	30	Mesh removal, AB
Beloosesky et al.[8]	74	Sacrocolpopexy	Osteomyelitis, epidural abscess	50	Laminectomy, AB
Brito et al.[9]	61	Laparoscopic hysterectomy, sacrocolpopexy, transobturator sling	Spondylodiscitis	12	Mesh removal, AB
Cailleux et al.[10]	54	Hysterectomy, sacrocolpopexy	Spondylodiscitis	66	Mesh removal, AB
	41	Hysterectomy, sacrocolpopexy	Spondylodiscitis	91	AB
	55	Hysterectomy, sacrocolpopexy	Spondylodiscitis	66	AB
	56	Hysterectomy, sacrocolpopexy	Spondylodiscitis	115	AB
	59	Hysterectomy, sacrocolpopexy	Spondylodiscitis	76	AB
Collins et al.[11]	74	Sacrocolpopexy	Mesh erosion, infected IVC thrombus, sacral osteomyelitis, epidural abscess	2920	IVC filter, mesh removal and abscess debridement, AB
Cosson et al.[12]	45	Laparoscopic sacrocolpopexy	Spondylodiscitis	730	Mesh removal, AB
Cranney et al.[13]	72	Open sacrocolpopexy	Osteomyelitis and presacral abscess	30	Mesh removal, discectomy, spinal fusion, AB
Dalwai et al.[14]	NA	Laparoscopic sacrocolpopexy	Spondylodiscitis	7	NA
	NA	Laparoscopic sacrocolpopexy	Spondylodiscitis	7	NA
Descargues et al.[15]	54	Laparoscopic hysterectomy, sacrocolpopexy salpingectomy	Spondylodiscitis	540	AB
Downing[16]	52	Laparoscopic sacrocolpopexy	Spondylodiscitis, epidural abscess, with a rectovaginal fistula	420	Abdominal hysterectomy, salpingo-oophorectomy, mesh removal, AB
Draaisma et al.[17]	45	Laparoscopic ventral rectopexy	Spondylodiscitis with infiltration in the spinal canal	30	Mesh removal, deviating colostomy, AB
	55	Laparoscopic ventral rectopexy	Spondylodiscitis and osteomyelitis	60	AB
Feng et al.[18]	64	Robotic hysterectomy, sacrocolpopexy, urethral sling	Osteomyelitis	30	Mesh removal, AB
Grimes et al.[19]	63	Robotic sacrocolpopexy, retropubic vaginal tap	Spondylodiscitis and osteomyelitis	120	1. Mesh removal and debridement of the infected area 2. Exposure of the posterior spine with screw placement 3. Anterior L4-5 discectomies and corpectomies 4. Posterior iliac screws and spine fusion, AB
Hart and Weiser[20]	42	Hysterectomy, bilateral salpingo-oophorectomy, pubovaginal sling sacrocolpopexy	Mesh erosion, osteomyelitis and spondylodiscitis	150	1. Mesh removal 2. Laparotomy, sacral debridement, partial vaginectomy
Jenson et al.[21]	67	Laparoscopic hysterectomy, bilateral salpingo-oophorectomy, sacrocolpopexy, transobturator sling	Mesh infection with spondylodiscitis and osteomyelitis	120	Mesh removal, AB
Kapoor et al.[22]	63	Laparoscopic sacrocolpopexy	Spondylodiscitis	21	AB
Muffly et al.[23]	46	Laparoscopic hysterectomy, bilateral salpingooophorectomy, sacrocolpopexy	Osteomyelitis, epidural abscess, vaginal fistula to the sacrum	180	Laparotomy, mesh removal, discectomy, AB
Nosseir et al.[24]	55	Robotic hysterectomy, sacrocolpopexy, transobturator suburethral sling	Spondylodiscitis and osteomyelitis	70	AB
Núñez-Pereira et al.[25]	80	Sacrocolpopexy	Rectosacral fistula, spondylodiscitis, epidural abscess	2520	1. Abscess debridement, lumbar fusion 2. L1- L4 decompression 3. Mesh removal, rectosigmoidal resection, protective loop ileostomy
Pasquer et al.[26]	76	Laparoscopic rectopexy and cystopexy	Spondylodiscitis, rectal fistula	30	Hartmann’s procedure, AB
Probst et al.[27]	81	Laparoscopic resection rectopexy	Spondylodiscitis	90	AB
Propst et al.[28]	66	Laparoscopic sacrocolpopexy, ventral rectopexy and transobturator sling	Spondylodiscitis	60	1. Laminectomy 2. Discectomy, mesh removal, AB
	55	Hysterectomy, sacrocolpopexy	Mesh erosion, spondylodiscitis	1095	1. Mesh removal 2. Mesh removal, surgical abscess debridement, AB
Rajamaheswari et al.[29]	42	Hysterectomy sacrocolpopexy	Mesh erosion, spondylodiscitis	42	Mesh removal, AB
Salman et al.[30]	59	Sacrocolpopexy	Spondylodiscitis	120	Abscess debridement, posterior stabilisation, AB
Taylor et al.[31]	64	Laparoscopic hysterectomy salpingo-oophorectomy, Burch urethropexy, sacrocolpopexy, posterior vaginal repair	Mesh erosion, osteomyelitis, epidural phlegmon	465	Mesh removal, laminectomy, AB
Voelker et al.[32]	58	Sacrocolpopexy	Spondylodiscitis, osteomyelitis	1095	1. Removal of the neovagina, debridement, excision of the intervertebral disk with bone graft replacement 2. Dorsal instrumentation of the segments L5-S1
Vujovic et al.[33]	50	Laparoscopic ventral rectopexy	Spondylodiscitis, osteomyelitis	42	Surgical screw removal, AB
Weidner et al.[34]	67	Open sacrocolpopexy	Spondylodiscitis, osteomyelitits, perivertebral phlegmon	1825	AB
	56	Open hysterectomy, sacrocolpopexy	Spondylodiscitis, osteomyelitits, epidural abscess	120	AB

AB: Antibiotics, IVC: Inferior vena cava

Forty-two 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. Initial surgery consisted of SC (n = 34), VR (n = 4), PR (n = 2) and combined sacrocolporectopexy (n = 1). Pexy was performed using synthetic meshes (n = 32), biologic meshes (n = 2), direct sutures (n = 5) and was not specified twice (n = 2). Meshes were fixated to the promotorium with sutures (n = 18), with non-absorbable tacks (n = 10), and no information on the fixation technique was available for the other patients (n = 6). 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 as potential direct infection route. The treatment of SD consisted of conservative treatment with antibiotics alone in 29% (n = 12), whereas 66% (n = 28) patients had to undergo additional surgical treatment. If a revision surgery was necessary, more than one surgical intervention was performed in 40% of the patients (11/27). Mesh (n = 20) and tack excision (n = 1) were performed in most cases, whereas a neurosurgical intervention was necessary in 10 patients. In two cases, the treatment was not specified. These results are summarised in Table 2.

Table 2

Baseline characteristics, presenting symptoms and type of treatment (n=41)

	n (%) or median (range)
Age (years)	59 (54-66)
Gender (male:female)	0:41
Initial surgery
Colpopexy	34 (83)
Rectopexy	6 (15)
Combined sacrocolporectopexy	1 (2)
Time to complication (days)	76 (30-165)
Symptoms
Back pain	35 (85)
Fever	20 (49)
Pain radiating in legs	9 (22)
Vaginal discharge	6 (15)
Access
Laparoscopic	17 (41)
Robotic	6 (15)
Open	2 (5)
Not specified	16 (39)
Fixation technique
Synthetic mesh	32 (78)
Nonabsorbable direct suture	5 (12)
Biological mesh	2 (5)
Not specified	2 (5)
Mesh fixation
Suture	18 (44)
Nonabsorbable tack	10 (29)
Not specified	6 (15)
Mesh erosion	8 (20)
Vaginal mesh erosion	7 (17)
Rectal mesh erosion	1 (2)
Fistula	7 (17)
Treatment
Reoperation/antibiotics	27 (66)
Antibiotics alone	12 (29)
Not specified	2 (5)

DISCUSSION

Even though PR, VR and SC are associated with a low risk for morbidity, SD is a very rare complication with, however, severe consequences. SD is described following sacropexy with and without the use of a mesh. SD often requires surgical revision and a long time to fully recover. In a large dual-centre study on 919 consecutive patients, the incidence of SD after laparoscopic VR was 0.3%.[35] SD generally results from haematological seeding of bacteria from a distant focus and less often occurs from direct bacterial inoculation, for example, after trauma, surgery or spread from adjacent tissue. SD after PR may be due to direct inoculation trough inadvertently deep placed stiches or tacks and consecutive bacterial translocation from the rectum or vagina. Furthermore, mesh erosion may predispose to infections, as the epithelial barrier may be injured and translocation from the vagina or rectum to the mesh and consecutively to the fixation site at the sacral promotontory may lead to SD Mesh erosion after VR and SC varied greatly across studies and rates from 1.3%–6% were reported.[353637] On the other hand, distant seeding has been shown as an alternative cause for SD, and the study by Propst et al. found a vaginal or urinary tract infection in 35% preceding the diagnosis of SD.[28]

The review revealed that the most common symptoms of SD after PR, VR and SC were back pain, pain radiating in the legs, fever and vaginal discharge. Interestingly, the time from initial procedure to the diagnosis of SD varied greatly and ranged from 6 days to 8 years. The diagnosis of SD may be challenging. Inflammation parameters, blood- and urine cultures should be performed as well as a gynaecological evaluation for vaginal infection. Nevertheless, even if infection parameters and cultures remain inconclusive in the presence of typical clinical symptoms imaging studies of the lower spinal cord should be performed without delay. Compared to radiography or CT, MRI is the most sensitive (93%–96%) and specific (92%–97%) imaging modality for diagnosis of SD For definitive diagnosis, a CT-guided, endoscopic or open biopsy may be considered.[38]

In general, SD responds well to treatment with antibiotics, and it is reported to be successful in 50%–75% of cases.[38] Empirical therapy may be started with penicillin or first-generation cephalosporin before microbiological results are available. Intravenous antibiotic therapy is recommended for 4–8 weeks, after that a 3-month course of oral antibiotic therapy should follow.[39] Our review, however, showed that conservative treatment was less often sufficient and surgical therapy was needed in around 70% of the cases. This fact may be attributed to a higher rate of direct inoculation of bacteria then by the more typical haematological seeding. Furthermore, conservative treatment is complicated by prosthetic material that serves as infection route and reservoir for bacteria. Therefore, a more aggressive approach is warranted in SD after PR, VR and SC. Surgical treatment usually includes mesh removal or in case of nerve compression or spinal instability laminectomy, discectomy and spine-stabilising procedures.

Surgeons are able to minimise the risk of SD by carefully placing the presacral fixation. It is advisable to expose the anterior ligament at the level of the promontory of the sacrum until its exact visual identification. The stiches or tacks should be placed into the anterior longitudinal ligament avoiding the disc space. One has to keep in mind that the anterior longitudinal ligament is only 1–2 mm thick.[40] Interestingly, the study by Unger et al. compared results between laparoscopic SC and robotic-assisted SC in 406 women. Postoperative osteomyelitis was found in 5.6% of the robotic-assisted SC compared to 0% after laparoscopic SC (P < 0.001).[41] The finding may be explained by a decreased haptic feedback in case of robotic surgery, and laparoscopic surgery may, therefore, be more suitable for accurate stitch placement. In case of PR, the sutures of the rectosacropexy should be placed distal and in good distance from the anastomosis to avoid contamination. Any tension on the anastomosis must be avoided.

CONCLUSION

When performing PR, VR or SC surgeons must be aware of the potential risk of SD Careful suture or tack placement into the anterior longitudinal ligament at the level of the sacral promontory while avoiding the disc space is of paramount importance. After the procedure, patients should be informed that back pain and fever should raise suspicion for SD Prompt diagnosis by MRI and multidisciplinary management are the cornerstones of a successful treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethics approval and consent to participate

Written informed consent was obtained from the patient for publication of the case and accompanying images.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.