Abdominal Sacrocolpopexy for Repair 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.

Robotic Vaginal Hernia Repair for Recurrent Vaginal Prolapse Status Post-Radical Cystectomy with an Indiana Pouch

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse following a radical cystectomy is challenging to treat and recurrence of prolapse after primary repair is common owing to compromised pelvic floor support and tissue quality. Vaginal prolapse repairs are often preferred because of concern for patients' complex intraabdominal pathological conditions. However, for those with recurrent prolapse following colpocleisis, limited definitive treatment options exist.

METHODS

This surgical video presents a 64-year-old G4P4 with a history of radical cystectomy with an Indiana Pouch for invasive urothelial carcinoma who presented with recurrent stage IV vaginal prolapse two years following colpocleisis. Owing to thin vaginal tissue, a sacrocolpopexy with vaginal mesh could not be performed, thus, the patient underwent robotic-assisted vaginal hernia repair with a polypropylene-reinforced ovine tissue matrix attached to Cooper's ligament and the levator ani muscles.

RESULTS

The surgery was free from complications and her postoperative Pelvic Organ Prolapse Quantification examination revealed a leading vaginal tissue remnant at the level of the hymen. The patient reported overall improved health and quality of life following surgery and recovery on postoperative validated questionnaires.

CONCLUSIONS

Vaginal and pelvic floor hernia repair with a polypropylene-reinforced tissue matrix is a feasible definitive surgical treatment for patients with prior radical cystectomy in whom colpocleisis has failed.

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.

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.

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.

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.