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AUGS/IUGA Scientific Meeting 2019
Enterocele Repair and Colpocleisis in a Woman Foll ...
Enterocele Repair and Colpocleisis in a Woman Following Radical Cystectomy
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Video Transcription
Transvaginal enterocele repair and copochliasis in a woman following radical cystectomy. An estimated 18,810 cases of bladder cancer will be diagnosed in women during 2018 in the US. Standard of care for muscle-invasive disease in patients desiring surgical therapy includes radical cystectomy with pelvic lymph node dissection and urinary diversion. Women undergoing radical cystectomy experience compromise of pelvic floor support structures has extirpative surgery, results in shortening of the anterior vaginal wall, weakening of pelvic floor musculature, and creation of a potential space that is prone to bowel prolapse. Current techniques do not routinely include resuspension of the apex or obliteration of the cul-de-sac. We present the case of a non-sexually active 71-year-old woman with a history of high-grade muscle-invasive bladder cancer diagnosed in 2016. She underwent robot-assisted laparoscopic radical cystectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node dissection, urethrectomy, and ileal conduit urinary diversion. She presented to clinic two years after surgery with complaints of pelvic pressure and a vaginal bulge. Physical exam revealed a healthy ileal conduit stoma, absent urethra, shortened vaginal length, and stage 4 vaginal vault prolapse with enterocele. She elected definitive surgical therapy. A self-retaining retractor with sharp blue hooks is used for exposure throughout the case. Alice clamps are placed to preserve at least 2 cm of vaginal epithelium and allow for closure across the midline at the end of the case. Hydrodissection is performed with 1% lidocaine and epinephrine, and a circumferential incision is made and the vaginal epithelium is marked. The underlying enterocele sac is dissected off the vaginal epithelium to the level of the pubic synthesis with a combination of sharp and blunt dissection. The peritoneum is entered sharply. Meticulous care is acquired and attention paid to adhesions involving small bowel that is frequently associated with the posterior aspect of the pubic synthesis following radical cystectomy. A curved navratil is used for additional exposure, and dissection is continued circumferentially. The bowel is packed cephalad into the abdominal cavity, and the enterocele sac is ligated as high as possible within the peritoneal cavity to prevent prolapse of the small bowel into the obliterated vagina. The vaginal epithelium is excised, and the bowel is again packed high within the peritoneal cavity. A permanent 2-0 Gore-Tex suture is placed through the remnant of the left uterus sacral ligament, and is continued across the midline along the anterior surface of the rectum, and completed over to the right uterus sacral ligament. A second, more distal suture is identically placed to help strengthen the repair. These are set aside for later tying, which helps to reduce tension on the upcoming purse string. 2-0 PDS is selected, and placed at the base of the enterocele sac, just distal to the previously placed Gore-Tex. The PDS is placed in a purse string manner. The bowel packing is removed, and the Gore-Tex sutures are tied down first to reduce tension on the purse string. The PDS purse string is then tied. An additional 2-0 Gore-Tex suture is placed in a purse string fashion to further buttress the enterocele repair. Excess vaginal epithelium is excised sharply, and a tension is then directed toward closure of the vaginal entroitis to completely obliterate the pelvic outlet. Four Alice clamps are placed to demarcate the vaginal fourchette in a diamond pattern. Hydrodissection is performed with 1% lidocaine with epinephrine, and a 15 blade is used to excise a diamond-shaped wedge of vaginal epithelium to expose the underlying puborectalis muscles. Sharp dissection is performed both sides laterally to expose the puborectalis muscles further. The rectum is swept medial with the operator's left hand. The puborectalis muscles are then sequentially placated across the midline with interrupted OPDS. These are tagged for later tying to facilitate adequate exposure of the distal puborectalis while the repair continues. A rectal exam is necessary to confirm no suture has been passed into the rectum, and the sutures are then tied down. The medial aspect of the bolocavernosus muscles are then placated with interrupted ovicral sutures. Tension from the retracting hooks is relieved prior to tying down the knots. Closure of the bolocavernosus muscles is then continued up to the level of the anterior fourchette. Interrupted ovicral is then used to completely close the introitus. Finally, 3-ovicral is used to re-approximate the vaginal epithelium in a running fashion. The patient tolerated the procedure well. She was discharged home on post-operative day 1 and returned to clinic 6 weeks later with complete resolution of her bulge and pelvic pressure. Exam revealed excellent anatomic success. Transvaginal repair of enterocele after radical cystectomy can be challenging due to altered anatomy. With meticulous dissection, we achieved a safe, effective, and durable cure for her symptoms. Consideration should be given to appropriate vaginal resuspension at the time of radical cystectomy to prevent this post-operative complication.
Video Summary
The video discusses transvaginal enterocele repair and copochliasis in a woman following radical cystectomy. It highlights the challenges faced by women undergoing radical cystectomy, including compromise of pelvic floor support structures and the potential for bowel prolapse. The case study focuses on a 71-year-old woman who underwent several surgeries and presented with pelvic pressure and a vaginal bulge. The surgical procedure involved dissecting the enterocele sac, removing the vaginal epithelium, and strengthening the repair using sutures. The patient experienced complete resolution of her symptoms after the surgery. The video emphasizes the importance of considering vaginal resuspension during radical cystectomy to prevent such complications. No specific credits are mentioned.
Asset Caption
Jason M Sandberg, MD
Keywords
transvaginal enterocele repair
copochliasis
radical cystectomy
pelvic floor support structures
bowel prolapse
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