Abstract
OBJECTIVE
Pelvic organ prolapse is an increasingly reported complication following anterior
pelvic exenteration and usually consists of an anterior enterocele.
1
,
2
,
3
,
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.
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References
- Spontaneous transvaginal bowel evisceration.Indian J Urol. 2013; 29: 139-141https://doi.org/10.4103/0970-1591.114038
- Vaginal deheiscence and evisceration after robotic-assisted radical cystectomy: a case series and review of the literature.Urology. 2019; 134: 90-96https://doi.org/10.1016/j.urology.2019.09.009
- Transvaginal pelvic organ prolapse repair of anterior enterocele following cystectomy in females.Int Urogynecol J Pelvic Floor Dysfunct. 2009; 20: 411-415https://doi.org/10.1007/s00192-008-0786-5
- Management of pelvic organ prolapse after radical cystectomy.Curr Urol Rep. 2019; 20: 71https://doi.org/10.1007/s11934-019-0941-1
Article info
Publication history
Published online: June 02, 2020
Accepted:
May 14,
2020
Received:
April 15,
2020
Footnotes
Declaration of Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Financial Disclosure: The authors declare that they have no relevant financial interests.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
