Pseudoaneurysm of the Internal Pudendal Artery Causing Delayed Vaginal Hemorrhage After Robotic-Assisted Total Hysterectomy: A Case Report.

Pseudoaneurysm is a rare but potentially life-threatening cause of delayed postoperative hemorrhage. Although pseudoaneurysms are well described after obstetric and gynecologic procedures, involvement of the internal pudendal artery after hysterectomy is extremely rare. A 50-year-old nulligravid woman underwent robot-assisted total hysterectomy with bilateral salpingectomy for symptomatic uterine leiomyomas. During transvaginal specimen retrieval, vaginal wall lacerations occurred bilaterally and were sutured intraoperatively. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. On postoperative day 22, she presented with vaginal bleeding originating from the sutured site on the right vaginal wall. Initial transvaginal suturing achieved temporary hemostasis; however, recurrent bleeding occurred later the same day. Three-dimensional computed tomography angiography revealed active extravasation from a pseudoaneurysm arising from a branch of the right internal pudendal artery. Transcatheter arterial embolization using gelatin sponge particles successfully controlled the bleeding. Transvaginal specimen retrieval caused pseudoaneurysm formation of the internal pudendal artery. Transcatheter arterial embolization is an effective and minimally invasive treatment option.