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evaluation of her current complaint revealed a mobile urethra , stable cystometrogram , and complete bladder emptying .
she had a positive cough stress test with a valsalva leak point pressure of 119 cm h2o with 150 ml of fluid in the bladder .
one hour after surgery , she complained of lower abdominal pain , a feeling of lower abdominal distension , and nausea .
her hemoglobin changed from 12.7 g / dl preoperatively to 8.3 g / dl about 2 hours postoperatively . computed tomography ( ct ) revealed a retropubic hyperdense hematoma sized up to 10 cm9 cm8 cm and active contrast leakage from the left internal pudendal artery ( fig .
the arteriography also confirmed left internal pudendal arterial injury , which was successfully treated by selective embolization with a gelatin sponge ( gelfoam , pfizer inc .
, new york , ny , usa ) ) with 25% n - butyl - cyanoacrylate ( fig .
the patient 's postoperative course was uneventful requiring neither blood transfusion nor surgical removal of the hematoma .
two years after surgery , her stress incontinence was resolved , and she complained of mild urge incontinence .
since the tvt procedure was introduced , it has become the gold standard for the treatment of female stress urinary incontinence .
although this method is minimally invasive , various complications have been reported even though the complication rate is low .
new minitapes , such as tvt - secur , may be a way to reduce such perioperative complications .
the tvt - secur system was developed with the intention of further reducing the invasiveness of the surgical procedures by avoiding the passage of the needle carriers through the retropubic or obturator regions .
the advantages of this new technique are thus related to the short passage of the needles , which minimizes the risk of vascular , nerve , or visceral injury .
the tvt - secur system was designed to overcome two of the perioperative complications reported with the use of the tvt - obturator : thigh pain and bladder outlet obstruction .
these complications were addressed by tailoring the tape to a length of only 8 cm and anchoring the tape edges into the internal obturator muscle , rather than passing it through the obturator foramen , muscle , and membrane . however
, a possible reason for hemorrhagic complications of the tvt - secur procedure may be the scalpel - shaped tip of the inserter , which can cut the vessels .
minor intraoperative bleeding from the initial vaginal dissection can usually be controlled with direct pressure on the paraurethral and retropubic areas , held for 5 to 10 minutes and followed by vaginal packing .
greatly increased bleeding that results in a retropubic hematoma usually arises from a venous injury during trocar passage , and up to 2.8% of these cases may require transfusion .
depending on the size of the hematoma , signs and symptoms may include pain , urgency and frequency from bladder compression , a suprapubic mass , hypotension , tachycardia , lightheadedness , vaginal and abdominal tenderness , and a decrease in hematocrit .
interestingly , specified bleeding from an internal pudendal artery has not been reported previously with the tvt or tvt - obturator technique .
reported in research carried out on 141 cases of tvt - secur that no injuries to the vessels and no hematoma were observed .
.   demonstrated that no bleeding or hematoma occurred during their 91 cases of the tvt - secur procedure .
however , severe bleeding from the internal obturator muscle and injury of the corona mortis after tvt - secur have been reported .
if abnormal abdominal pain or abdominal distension appears after the tvt - secur procedure , a ct scan should be performed .
the patient should also be carefully examined if other complications occur , such as buttock or groin pain , signs of shock , vaginal bleeding , or urinary retention . to decrease the risk of vascular injury
, the pelvic surgeon should pay attention to proper technique during the approach and have a high clinical suspicion of complications under the appropriate circumstances .
various postoperative complications have been reported after the use of tension - free vaginal tapes ( tvt ) . 
 the transobturator approach was introduced to minimize the potential complications . 
 the next generation of recently introduced tvt - secur is intended to minimize the incidence of complications . 
 herein we report a case of internal pudendal artery injury sustained during this procedure that was successfully treated by radiological embolization . 
 angiography with vessel embolization , when available , should be considered when the arterial injury is suspected .