Anterior Enterocele After Radical Cystectomy

Introduction

The occurrence of pelvic organ prolapse (POP) after radical cystectomy (RC) has been reported uncommonly, while the prevalence may be higher. ¹ The potential for a hostile abdomen/pelvis from that surgery and concomitant loss of connective tissue support and vaginal tissue makes surgical repair challenging and predisposes repairs to fail. Pessaries may not be feasible because of alterations in vaginal geometry and weakness of pelvic-floor muscle tone.

This article reports the current author's experience with a transvaginal prolapse repair in a woman after RC.

Case

A 73-year-old woman presented with a stage 3 symptomatic anterior enterocele 2 years after RC. She no longer desired coital function. A ring pessary was tried, but she was unable to retain it comfortably. She was counseled about colpocleisis and partial vaginectomy. A midline incision was created over the enterocele, which led to immediate entry into the peritoneal cavity. The incision was continued over the posterior vaginal wall, dissecting laterally, and exposing intact posterior connective tissue and the levators. The apical edge of connective tissue was used as an anchor for 2 purse-string sutures of 2-0 polydioxanone. A levator plication was performed over the length of the vagina to form a midline septum distal to the purse-string closure. Perineal skin had been previously removed in preparation for a high perineorrhaphy in continuity with the levator plication. Excess vaginal epithelium was excised and the vagina was closed. Vaginal length was 5 cm, and the genital hiatus was <2cm.

Results

As of this writing the patient had been followed for 18 months without recurrence. She also remained disease-free from bladder cancer at the follow-up.

Discussion

In females, RC involves the removal of the uterus, fallopian tubes, ovaries, bladder, and some of the anterior vaginal wall. After RC, small and large bowel can herniate through the anterior vaginal wall, with formation of an anterior enterocele. While the mechanism of recurrence after surgery for POP is not completely understood, the anatomical shortcomings that predispose women after RC for POP predispose repairs to fail (i.e., the surgical absence of endopelvic fascia and uterosacral/cardinal ligamentous support).^1,2 Pessary use may be limited not only by altered vaginal geometry, but by how atretic and avascular the vaginal epithelium is and the potential for ulceration and evisceration. At surgery, it was not possible to remain extraperitoneal, as in a typical colpocleisis or mesh interposition repair, and entering the peritoneal cavity was unavoidable. Anatomical landmarks (extraperitoneal) that exist regardless of having had an RC include: the sacrospinous ligaments; iliococcygeal fascia; and connective tissue of the posterior vaginal wall. Consideration should be given to utilizing this tissue not affected by the RC.

There are 7 published cases of transvaginal prolapse repair after RC, the majority of which utilized mesh or biologic reinforcement.^1,2

As in the current case, some form of colpocleisis was utilized in 3 patients by Stav et al. ¹ In one, “redundant anterior vaginal epithelium was excised and the anterior hernia orifice was closed with numerous purse string sutures”—with no recurrent prolapse at 10-month follow-up. In another case, involving evisceration of small bowel—because the endopelvic fascia and levator ani muscles were grossly edematous and weak—a purse string suture was used to close the enterocele and “then a rectangular piece of posterior vaginal [sic] was excised, and the anterior and posterior mucosa along with endopelvic fascia and puborectalis muscle fibers were then sutured together.” At 6 months, the prolapse had recurred. Although a third operation was not labeled as a colpocleisis by the researchers, that patient had an anterior vaginectomy with closure of the hernial sac at the level of the pubic rami with a number of purse string sutures. “A layered epithelial layer closure” followed and the posterior vaginal wall was left intact. There was no recurrence of the prolapse at the patient's 5-month follow-up, but she died from metastatic disease. The other 2 patients had mesh repairs, 1 with a transobturator polypropylene kit after a biologic repair failed, and 1 with a composite mesh sutured to the bilateral iliococcygeal fascia. ¹

In Graefe et al.'s two repairs utilizing the Elevate ^tm Anterior and Apical Prolapse Repair System (American Medical Systems), no recurrent prolapse was identified at 16 and 4 months postoperatively. ²

The currently published literature regarding colpocleisis is limited in quality. There is no Level I or II evidence to guide clinical care with respect to operative technique, and concomitant surgical procedures; features of many of the procedures referred to as “colpocleisis” are unstandardized and/or poorly described. ³ Even in Stav et al.'s series, differing techniques were used—and none utilized a levator plication as such. ¹ Restriction of the genital hiatus via concurrent levator ani and fascia plication and/or high perineorrhaphy has been suggested as a means of reinforcing support and prevention of prolapse recurrence, ³ but, in the current author's experience, these techniques are not routinely performed. ⁴ In a 2015 retrospective study, the only factors that contributed to recurrent POP after Le Fort colpocleisis were greater postoperative vagina length and a wider genital hiatus. ⁵

In the current patient, it seemed intuitive not only to narrow the genital hiatus, but to perform a levator plication along the entire length of the vagina to provide a distal anatomical septum to “obstruct” the apex, given the anatomical lack of tissue to reconstruct. Levator plication, as part of a colpocleisis, is the current author's standard practice for routine patients opting for obliterative surgery and the current author feels that this adds to the durability of the repair.

Conclusions

Colpocleisis is a satisfactory technique for repair of POP after RC and presents some unique anatomical challenges. Perhaps the best way to deal with post-RC enterocele formation is to prevent it by being cognizant of the supporting structures within the female pelvis and limiting the amount of endopelvic fascia excised at the time of RC. Prophylactic attachment of the remaining vaginal vault to the uterosacral/cardinal ligament complex may help lower the risk of vault prolapse.