We would like to present a case of surgical management in a patient with prolapse after anterior exoneration. This patient was a 71-year-old P0. She had a history of muscle-invasive bladder cancer. She underwent robotic-assisted laparoscopic anterior exoneration with removal of her bladder and uterus. She also had pelvic lymph node dissection and creation of an Indiana pouch in 2013. She did not require chemotherapy or radiation after surgery. After her index cancer surgery, she was referred to Urogynecology Service and was found to have stage 3 prolapse. Her apex and what was left of the anterior compartment prolapsed 4 centimeters outside of the hymen. She was treated with pessaries. However, over the years, her prolapse became worse. Multiple pessary changes were required over the years, including ring pessary and galehorn pessary. Finally, in 2019, she wished to proceed with definitive surgical management. She wished to have vaginal pelvic reconstruction and declined vaginal obliteration procedures. Her case was discussed extensively with her urologist. Her urologist did not recommend abdominal approach to repair her prolapse, including abdominal secro-colpopexy due to the location of her Indiana pouch. Upon further discussion with her urologist, it was noted that at the time of her anterior exoneration, only the uterus and bladder were removed. The urologist did not carry out dissection deep in the pelvis to remove the remnants of utero-sacral ligaments. Therefore, the decision was made to proceed with vaginal pelvic reconstruction with apical suspension uterizing utero-sacral or sacro-spinous ligaments. These pictures show the extent of her stage 4 prolapse. The arrows show what is left of the anterior compartment after anterior exoneration. Before her surgery, the urine in her Indiana pouch was drained. The prolapse vagina was grasped with multiple alloce clamps. The prior utero-sacral ligament incision site at the bilateral cuff was identified. The prior utero-sacral ligament incision site was tagged with vicral sutures on both sides. Her vertical skin incision was made from the anterior compartment to the superior part of the perennial body. The vaginal epithelium was then reflected away from the underlying fascia. The peritoneum was entered easily without any difficulty due to the absence of the interior compartment. A vaginal packing was then gently placed in the abdomen to pack the bowel away. Two suspensory sutures were then placed on the utero-sacral ligaments on both sides. The first suture was a zero PDS suture, followed by one 2-0 ethibond suture at the sacral site. The remnant of anterior vaginal epithelium was then excised. The remnant of the anterior compartment was then rebuilt using 2-0 ethibond sutures. The four utero-sacral ligament suspensory sutures were then passed through the reconstructed anterior compartment and also the posterior compartment. The four suspensory sutures were then tied down towards the apex and also given excellent support to the apex. This picture shows the reconstructed vagina. Now her vaginal ensured is measured about 4 cm. Her vaginal depth measured 10 cm. At the end of the surgery, a straight catheter was used to empty her Indiana pouch again. The patient's urologist did not recommend performing cystoscopy through the Indiana pouch to evaluate for urital patency due to the location of the Indiana pouch being far away from the pelvis. The total surgical time was 80 minutes. Typically, cystoscopies are performed to ensure that the ureters and the bladder are not injured. The CT scan illustrates that the pouch and the ureters are well away from the area of the prolapse surgery field. The arrow on the left-hand side shows where the Indiana pouch is located. The arrow on the right shows where the pessary was before prolapse surgery. In summary, we show that vaginal native tissue pelvic reconstruction is feasible in patients with a history of pelvic exoneration. We recommend a team approach and discussion with all specialties, including GYN oncologists, urogynecologists, and urologists, before proceeding with surgery for treatment planning. In order to prevent prolapse after pelvic exoneration, one should consider performing concurrent prophylactic apical suspension at the time of initial cancer surgery.

surgical management

prolapse

anterior exoneration

bladder cancer

robotic-assisted laparoscopic