Management of Pelvic Organ Prolapse After Radical Cystectomy

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.

Operative time tracking for umbilical hernia patients

BACKGROUND

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms.

METHODS

This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018.

RESULTS

A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant.

CONCLUSION

This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

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.

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.