Transvaginal pelvic organ prolapse repair of anterior enterocele following cystectomy in females

Anterior enterocele after cystectomy: case report and review of the literature

PURPOSE

Anterior enterocele is a rare but potentially serious complication after cystectomy with heterogeneous treatment options.

METHODS

Here we report on the management of a 71-year-old patient with recurrence of anterior enterocele after cystectomy and provide a systematic review of the literature using the PubMed/MEDLINE database.

RESULTS

The 71-year-old patient with recurrence of anterior enterocele after cystectomy was successfully treated with colpocleisis and anterior colporrhaphy at the Department of Gynecology and Gynecological Oncology, University Hospital Bonn. The use of a synthetic mesh was not needed. At 16-month follow-up postoperatively, the patient was asymptomatic and had no signs of recurrence. n = 14 publications including n = 39 patients were identified for the systematic review including case reports and reviews. The median duration of developing an anterior enterocele after cystectomy was 9 months (range 3 months to 8 years). Patients had a median age of 71 years (range 44-84). In all cases, a surgical approach was described using a wide variety of surgical procedures. In total, 36% of all patients developed a recurrence with an average time period of 7 months after primary surgery. A rare complication represents a vaginal evisceration with the need of urgent surgery. Furthermore, the occurrence of a fistula is a possible long-term complication.

CONCLUSION

Anterior enterocele after cystectomy is a rare complication requiring an individual and interdisciplinary treatment.

Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement.

METHODS

Female bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement.

RESULTS

Out of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02).

CONCLUSIONS

The type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

Transvaginal repair of enterocele following robot‐assisted radical cystectomy using a mesh for abdominal wall hernia repair

Introduction

This report aims to describe our experience in the pelvic floor reconstruction of anterior enterocele following radical cystectomy by transvaginal surgery using a mesh for abdominal wall hernia repair.

Case presentation

An 84‐years‐old woman developed pelvic organ prolapse 4 months after undergoing robot‐assisted radical cystectomy. After examination, she was diagnosed with a midline anterior enterocele. Considering the thinness of the vaginal wall and the large defect of the vaginal wall muscle layer, we performed transvaginal repair using a mesh for abdominal wall hernia repair designed to reduce the adhesion to the intestinal tract.

Conclusion

At the 1‐year follow‐up, neither recurrence nor complications were observed. This showed that transvaginal mesh surgery for abdominal wall hernia repair could be a treatment option for pelvic organ prolapse with a vaginal wall muscle layer defect after radical cystectomy.

Vaginal enterocele after cystectomy: A case report

BACKGROUND

After undergoing radical cystectomy combined with hysterectomy, female patients may suffer from pelvic organ prolapse due to the destruction of pelvic structures, which mainly manifests as the prolapse of tissues of the vulva to varying degrees and can be accompanied by symptoms, such as bleeding and inflammation. Once this complication is present, surgical intervention is needed to resolve it. Therefore, preventing and managing this complication is especially important.

CASE SUMMARY

The postoperative occurrence of acute enterocele is rare, and a case of acute small bowel vaginosis 2 mo after radical cystectomy with hysterectomy is reported. When the patient was admitted, physical examination revealed that the small bowel was displaced approximately 20 cm because of vaginocele. A team of gynecological, general surgery, and urological surgeons was employed to return the small bowel and repair the lacerated vaginal wall during the emergency operation. Eventually, the patient recovered, and no recurrence was seen in the half year of follow-up.

CONCLUSION

We review the surgical approach for such patients, analyze high-risk factors for the disease and suggest corresponding preventive measures.

Vaginal Complications after Radical Cystectomy for Bladder Cancer: A Systematic Review

OBJECTIVES

To summarize the published literature regarding pelvic organ prolapse, dehiscence or evisceration, vaginal fistula, and dyspareunia after radical cystectomy and to describe the management approaches used to treat these conditions.

METHODS

Ovid MEDLINE, Ovid EMBASE, and Web of Science were systematically searched from January 1, 2001 to January 25, 2021 using a combination of search terms for bladder cancer and radical cystectomy with terms for four categories of vaginal complications (prolapse, fistula, evisceration/dehiscence, and dyspareunia). A total of 229 publications were identified, the final review included 28 publications.

RESULTS

Neobladder vaginal fistula was evaluated in 17 publications, with an incidence rate of 3 - 6% at higher volume centers, often along the anterior vaginal wall at the location of the neobladder-urethral anastomosis. Sexual function was evaluated in 10 studies, 7 of which utilized validated instruments. Maintaining the anterior vaginal wall and the distal urethra appeared to be associated with improved sexual function. Pelvic organ prolapse was assessed in 5 studies, only 1 used a validated questionnaire and none included a validated objective measure of pelvic organ support.

CONCLUSION

There is a need for more prospective studies, using standardized instruments and subjective outcome measures to better define the incidence of vaginal complications after radical cystectomy for bladder cancer, and to understand their impact on quality of life measures.

Anterior enterocele as an etiology for anterior vaginal wall prolapse: a magnetic resonance defecography case series

Pelvic floor hernias from the posterior cul-de-sac most often contain small bowel and are called enteroceles, however may contain sigmoid colon (sigmoidocele) or only peritoneal fat (peritoneocele). These cul-de-sac hernias typically cause bulging of the posterior vaginal wall, while anterior vaginal wall bulges are typically secondary to bladder prolapse in patients with pelvic floor deficiency. We report a series of seven patients who presented with anterior vaginal wall "mass" or bulge after cystectomy and were found on magnetic resonance defecography (MRD) to have enteroceles or sigmoidoceles in the anterior rather than posterior compartment. MRD was instrumental for diagnoses in these patients and to exclude local recurrence of bladder malignancy. We also report five additional patients that were found to have bowel herniation anterior to the vaginal apex, but without history of cystectomy.

Anterior enterocele immediately after cystectomy: A case report

An enterocele is a peritoneal herniation through or into the vagina, typically as a posterior enterocele, which develops in the rectovaginal space (pouch of Douglas or cul-de-sac). An anterior enterocele in the vesicovaginal space is a rare condition, but a possible complication after cystectomy or hysterectomy. Herein, we report a rare case of anterior enterocele after cystectomy, which required semi-urgent intervention. The patient was a 78-year-old woman (gravida 2, para 2) who underwent laparoscopic radical cystectomy for bladder carcinoma 3 months earlier. Vaginal examination showed a large stage-3 anterior enterocele without the covering vaginal wall. A transvaginal surgery was performed to repair the vagina. Mesh and Martius flaps were needed to repair the vaginal defect. In conclusion, an anterior enterocele must be suspected when pelvic organ prolapse occurs after cystectomy, and surgical repair should be performed as soon as possible because an enterocele that lacks vaginal wall covering is at high risk of rupture.

Prolapse repair after anterior exenteration

This report presents our experience in performing prolapse repair after anterior exenteration. The patient had a history of invasive bladder cancer and underwent a robotically assisted laparoscopic anterior exenteration with extended bilateral pelvic lymph node dissection and creation of an Indiana pouch continent diversion. Her pelvic organ prolapse progressed over time despite multiple pessary fittings. She eventually decided to proceed with pelvic reconstructive surgery 6 years after her cancer surgery. She underwent a successful vaginal native tissue reconstruction with uterosacral ligament suspension, posterior repair and reconstruction of the anterior compartment. The patient has been followed for 16 months without recurrent prolapse. Vaginal native tissue pelvic reconstruction is feasible in a patient with a history of pelvic exenteration.

Transvaginal Repair of a Peritoneal-Vaginal Fistula

OBJECTIVE

Pelvic organ prolapse is an increasingly reported complication following anterior pelvic exenteration and usually consists of an anterior enterocele.^1-4 We present the surgical management of a peritoneal-vaginal fistula in a woman who presented with an acute enterocele 16 months following vaginal sparing, robot-assisted laparoscopic anterior pelvic exenteration.

METHODS

Our patient is an 85-year-old female with history of upper tract urothelial carcinoma who underwent a left nephroureterectomy in 2008, and vaginal sparing robot-assisted laparoscopic anterior pelvic exenteration for BCG-refractory carcinoma in situ of the bladder in August 2016. She presented in November 2017 with new onset vaginal bleeding and discharge. On physical examination, she had a dehisced vaginal cuff apex with a bulging enterocele. There were no signs of active evisceration or strangulation. The patient was no longer sexually active and desired surgical treatment. At the time of surgery, a mature peritoneal-vaginal fistula was identified, and the fistula and prolapse were surgically managed with colpectomy and colpocleisis.

RESULTS

Intraoperatively found to have a partial vaginal cuff dehiscence covered with granulation tissue, resulting in a 5 mm peritoneal-vaginal fistula. The granulation-covered enterocele sac was trimmed, dissected free, closed, and reduced with serial purse-string sutures. In this fashion, the sutures were used to not only reduce the fistula, but to also perform a colpocleisis and colpectomy. The colpocleisis and colpectomy were performed due to lack of supportive apical vaginal structures and patient desire. The serial purse-string sutures not only provided additional apical support, but also reduced the likelihood of fistula recurrence by covering the peritoneum.

CONCLUSION

Transvaginal peritoneal-vaginal fistula repair with serial purse-string sutures and partial colpectomy provides a technique for repair in patients who do not have supportive apical tissue following exenterative surgery. The ideal prevention of this problem at the time of cystectomy and management for when it occurs remains unclear.

Post-cystectomy Enterocele: A Case Series and Review of the Literature

OBJECTIVE

To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication and discuss opportunities for prevention. Women with muscle invasive bladder cancer undergo RC with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for POP.

METHODS

We present 4 cases of high-grade POP in women who underwent RC for bladder cancer. We reviewed the literature by conducting a Boolean search in PubMed with the terms "("radical cystectomy") AND ("enterocele" OR "pelvic organ prolapse" OR "rectocele" OR "vaginal vault prolapse")."

RESULTS

All 4 women reported a bulge sensation in the vagina and physical exam confirmed POP. Three had radiographic findings consistent with high-grade enterocele at rest. Three experienced prolonged intra-abdominal pressure rise post-RC that may have further weakened pelvic floor support, while the fourth had a history of surgery for high-grade POP. Nine articles on POP following RC were identified. Four focused on treatment and 3 focused on prevention.

CONCLUSION

Administration of a single validated question would have identified all 4 cases of postoperative enterocele and is sensitive to detect most women who are experiencing POP. Attention to the pelvic floor on cross-sectional imaging with identification of features that indicate POP, such as herniation of intestinal contents below the pubo-coccygeal line, will identify and/or confirm high-grade enterocele. Familiarity with risk factors for POP and identification of weakened vaginal wall support opens up the opportunity for prevention.

Recurrent Anterior Vaginal Wall Hernia after a Radical Cystectomy

True pelvic floor areas are uncommon conditions, but they can occur after extensive pelvic surgery including radical cystectomies or pelvic exenteration. We present the case of a patient with a persistent hernia that failed a native tissue repair and required a prosthetic mesh implant as definitive surgical treatment.

Management of Pelvic Organ Prolapse After Radical Cystectomy

PURPOSE OF REVIEW

This article explores the anatomy, management options, and outcomes of pelvic organ prolapse with a female cystectomy patient.

RECENT FINDINGS

There is a lack of data on surgical management outcomes for prolapse following radical cystectomy. However, most case series from tertiary referral centers show reasonable results irrespective of route of repair. As expected, the surgical planes and the reorientation of the bowel loop for urinary diversion makes any pelvic reconstruction a potential hazard and requires a high level of expertise and counseling to the patient in regard to the management of expectations. Pelvic organ prolapse following radical cystectomy is uncommon but presents a significant challenge to the reconstructive surgeon.

Laparoscopic pelvic organ prolapse repair by mesh interposition following radical cystectomy

Introduction

The present study aims to introduce laparoscopic treatment by the interposition of polypropylene mesh for a pelvic organ prolapse in females following radical cystectomy for treating muscle‐invasive bladder carcinoma.

Case presentation

The patients included two women aged 77 and 79 years with symptomatic enterocele following radical cystectomy and ileal conduit urinary diversion. We performed laparoscopic sacrospinous colpopexy using polypropylene and polypropylene/ePTFE composite meshes.

Conclusion

No recurrent prolapse occurred during 26 and 14 months of follow‐up after the operation. No severe perioperative complications were noted. This is a first report on cases of laparoscopic sacrospinous colpopexy for post‐cystectomy pelvic organ prolapse. Our procedure could be safely performed in two patients with post‐cystectomy pelvic organ prolapse.