Spontaneous Healing of Vaginal Cuff Dehiscence in a Uterine Cervical Cancer Following Laparoscopic Radical Hysterectomy and Chemoradiation

Introduction

Vaginal cuff dehiscence (VCD) after hysterectomy has a low incidence but can have serious complications. Given that there is no consensus about the ideal management of VCD, treatment depends on the patient's condition and presentation, particularly the presence of the eviscerated organ. Surgical repair is performed in most cases. ¹ Another factor affecting the management of VCD is whether or not radiotherapy is applied following a laparoscopic radical hysterectomy (LRH). Brachytherapy impairs wound healing and makes the vaginal mucosa rigid and fibrotic, so it becomes more difficult to repair the dehiscence surgically. ² This article reports on a case of VCD that developed in a uterine cervical cancer following LRH and chemoradiation. The VCD was managed expectantly and had spontaneous healing.

Case

A 51-year-old female underwent total laparoscopic nerve-sparing radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph-node dissection, for cervical squamous cell carcinoma, International Federation of Gynaecology and Obstetrics stage1B2. Final pathology testing revealed pT2bN0M0 with invasion of the left parametrium. It was recommended that she receive concurrent chemoradiation therapy 8 weeks after the surgery. Radiation therapy to the pelvis was delivered daily for 5 weeks with concurrent chemotherapy (a weekly bolus of 40 mg/m² of cisplatin), which was started on day 1 of radiotherapy for 5 times.

Three months after this concurrent chemotherapy, VCD with small-bowel at the vaginal opening was observed via a speculum examination, at the outpatient clinic on her regular follow-up (Fig. 1). This patient was asymptomatic. There were no signs of incarceration and infection. It was decided to wait for spontaneous vaginal closure and to reassess the condition of her vagina every 3 months.

OPEN IN VIEWER

FIG. 1.

Portion of small bowel entrapped into the vaginal cuff dehiscence seen on speculum examination (54 × 40 mm).

Results

Three months after her VCD diagnosis, this patient's vaginal opening became smaller and was already covered by a thin membrane. This membrane gradually became thicker and the vaginal opening was completely closed after 2 years. (Fig. 2A and B) She receives follow-up examinations regularly without recurrences noted as of this writing.

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FIG. 2.

(A) The membrane of vaginal opening partially healed after 1 year (50 × 18 mm). (B) The vaginal cuff dehiscence completely healed after 2 years (50 × 18 mm).

Discussion

VCD is a rare but severe morbidity following hysterectomy. Although the rates of VCD are different from study to study, robotic and laparoscopic hysterectomies have higher rates of VCD (ranges: 0.64%–4.1%, 0.47%–4.93%, respectively) than vaginal and abdominal hysterectomies (ranges: 0.13%–0.29%, 0.12%–0.99%, respectively).^3,4 This surgical risk factor is more associated with minimally invasive approaches because of the use of electrosurgery for colpotomy that is said to impair wound healing. ⁴ However, Fanning et al. reported that the vaginal closure technique plays a role in the increased VCD rate associated with total laparoscopic hysterectomy, not the electrosurgery. ⁵ Smoking, diabetes, chronic lung disease increasing intra-abdominal pressure, vaginal atrophy, advanced age, chronic steroid use, postoperative radiation therapy, sexual intercourse before healing, postoperative cuff infection, and hematomas are also associated with VCD.

In the current case, the risk factor associated with VCD was the use of electrosurgery for colpotomy and the postoperative radiation therapy given to the patient. There were no symptoms of infection and no history of sexual intercourse. Radiation therapy may impair wound healing and be the cause of VCD. Radiation disrupts the inflammatory, proliferative, and remodeling phases of wound healing and reduces nitric oxide, which promotes wound healing by induction of collagen deposition. ² This results in pathologic fibrosis and its complications, such as strictures and fistulae of the vagina, and can affect surgical outcomes of VCD.

Articles relevant to vaginal cuff dehiscence and cancer were reviewed in PubMed; in 12 journals, there were 38 cases of VCD following hysterectomy in gynecologic cancer.^1,3,6–15 Of these 38 cases, hysterectomies were performed abdominally in 3 cases, robotically in 29, and laparoscopically in 6. In 1 case, there was another dehiscence requiring a second repair. Although VCD can occur at any time after a hysterectomy, in this review, the time range of occurrence was 4 weeks to 10 months—within 1 year. Of the 38 cases, there were 12 of VCD following radiation therapy, and in 10 cases of those 12, the VCD occurred following minimally invasive hysterectomy. Of these 10, 3 cases of VCD were post robotic hysterectomies for endometrial cancer; the VCD occurred 6–9 weeks post surgery during the radiation treatment simulation using a vaginal cylinder. During vaginal brachytherapy, significant pressure from cylinder insertion can trigger dehiscence. Of these 10 patients, 7 patients underwent surgical closures; another 3 were allowed to heal by secondary intention.

The current patient had a complete disruption of the vaginal cuff with bowel evisceration. In the current authors' experience, the bowel has been viable with active peristalsis and there have been no ischemic injury, peritonitis, or sepsis. Thus, it was decided to await spontaneous healing of this patient's vagina.

Cronin et al. performed a review of original research, case reports, and case series published in the past 30 years on VCD. ⁴ These researchers reported that 5% of patients were allowed to heal by secondary intention after VCD or evisceration. Of the 73 cases of dehiscence that were found in that review, 3 patients (4%) each had another dehiscence that required a second repair. So, the higher rate of another dehiscence following radiation therapy was considered.

Conclusions

As most gynecologists noted in their reports, surgical repair was used to treat VCD. However, case reports on VCD occurring after radiation therapy are scarce. It may take time to heal a surgical wound completely following radiation therapy as shown in the figures (Figs. 1 and 2). However, in cases with rigid vaginal mucosa post radiation therapy or in patients with previous polysurgery wherein another surgery— either vaginal or abdominal—would be risky, nonclosure can be another option for approaching VCD. Otherwise, the most important thing is that one has to evaluate the patient's general condition to decide proper management of that individual patient's VCD.